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A.pPLICATTON <br /> 3 �,^ SAN JOAQUIN COUNTY PUBLIC VISION TH VICES PA <br /> �Iec ���P E <br /> h ENVIRONMENTAL HEALTH DIV <br /> 445 N SAN JOAQUIN, PHONE (2CA)95201420 4 oR 3rVED <br /> BOX 2009, STOCgTON, SqN� 1993 <br /> P O PUBLIC OAOUIN C !: <br /> PERM T EXPIRES 1 YEAR FROM c ATE at e) ISS RUM�EHEAL H SER CES <br /> (Complete in Trip �LTHin plYdShis <br /> San <br /> permit to construct atsnd°1$62 and ther-install Rulesanvork d Regulations o an I <br /> Application is hereby made to San Joaquin County n r a pe I <br /> application is made <br /> public inHeal�thianceServices- San Juin County Ordinance 190. 5 9 <br /> Joaquin Countytt �l Pr7 lot size/Acreage <br /> 0o ST <br /> t G City <br /> Job Address I N Phon r " <br /> I r ®.!� . <br /> t. �' `• Address zio9ci <br /> Owner's Name <br /> s{�1C License No. Phone <br /> �� � 10�, <br /> Address ,2 <br /> DES11111111 TRUCTION Out of Service Well ❑ <br /> Contractor WELL REPLACEMENT I Monitoring Wells <br /> NEW WELL ❑ OTHER ❑ - It)i 1 it((� <br /> TypE OF WELL/PUMP: _SYSTEM REPAIR ❑-- PRPP. LINE ui 3 <br /> PUMP INSTALLATION O. Y� DISPOSAL FLD. <br /> SEWER LINESOTHER WELL <br /> PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TAN.IC �--� AGRICULTURE WELL � <br /> k. FOUNDATION 1— I <br /> PROBLEM CONSTRUCTION SPECIFICA710NS <br /> INTENDED USE TYPE OF WELL Dia. of Well Casing <br /> C3 open Bottom 0 Manteca Dia:of WaN Excavation Specifications <br /> Cl tndustriel 0 Tracy Type of Casing Type of Grout------ <br /> Ll <br /> n QomesticlPrivate Gravel Pae <br /> {1 Delta Depth of Grout Seal <br /> i'I Public I.1 Other Surface Seal Installed by <br /> I I Irrigation Approxi Depth l I Eastern Stat rk r� O <br /> Type of Pump _ H.P. l TD <br /> Repair Work Done L3 r��"- ��i� i tit <br /> `� Well Diameter' -`rf��- material � � <br /> Wall Destruction riller Material i Depth S <br /> { F>tW f 03Depth tic system permitted if public sewer is <br /> available within 200 feet•} <br /> TYPE OF SEPTIC WORK: NEW 1NSTALtATION I I REPAlR1ADD1710N I l DESTRUCTION l 1 lNo sep <br /> Installation' 'Il serve: Residence_� <br /> Commercial— Other <br /> Number of Ilv1 units: Number of bedrooms W epth <br /> Character of 501110 depth of 3 feet'It <br /> Capacity No. Compartments <br /> SEPTIC TANK. TypelMlg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ oundetion Property Lina <br /> Distance 1 area: Well <br /> Total length/size <br /> 0 No. & Len th of Ii PropsrtY <br /> LEACHING LINE <br /> F g Foundation��- r Line <br /> FILTER BED O Distance: rest: We11 <br /> 1 Size Number <br /> SEEPAGE PITS Depth Propertli Line _.--�-- <br /> I±.. Wail�= Foundation <br /> SUMPS Ll 7Distance to nearest` <br /> S ❑ aquin county ordinances, stats laws, and <br /> DISPO POND <br /> 1 hereby certify that I have prepared this application tltd that the work will be done in accordance with San <br /> work for which this permit is issued, 1 shall not <br /> rules and regulations of the San Joaquin County 'I certify that in the performance of the <br /> Home owner or licensed agent's eigniture certifies the following: ' of <br /> employ any person in such manner at to becon eines of to <br /> he work far which th6s tpermitvi+iso ed.California," <br /> lt<haworkman's Ill employ perrons�sub{ect to ring of sub-contracting <br /> orktman's compensa- <br /> certifies the following: 11 certify that in'the pe <br /> tion laws of California." <br /> G The applicant call for all requir pe, n 1 a drawing on reverse side. y 4 <br /> �� �O i2 3 Date: <br /> Title: <br /> Signed <br /> f FOR DEP RTMENT USE ONLY <br /> Data Area <br /> k Application Accepted by Date <br /> I Pit or Grout Inspection by <br /> Date � Final inspection by <br /> 1 Additional Comments: <br /> Applicant - Return all copies to: $nviJoaquin roomental°Healthunty ublic Health Vices <br /> permit/Services <br /> 445 N San Joaquin, p O Box 2009, Stkn, OA 95201 <br /> K RECEIVED By DATE PERMIT'N0. <br /> FIE AMOUNT DUE AMOUNT REMITTED CASH - } <br /> INFO .,,cIP� 6 3 <br /> . EH 13-241(REV.I Rim <br /> 11414-26 <br />